CT and MR Enterography in the Evaluation of Celiac Disease

Celiac disease is a common inflammatory disease of the small bowel that induces mucosal intestinal lesions. The disease is mediated by an immune response and triggered by the ingestion of gluten in genetically predisposed individuals. Gluten contains gliadin, a component found mostly in wheat, barley, and rye. This process leads to gastrointestinal malabsorption with symptoms such as diarrhea, constipation, abdominal pain, and distention. It has a prevalence of 1%-2% in the general adult population, who present with symptoms at any age, but is more frequently found in adult women in the 3rd or 4th decade of life. Recognition of the disease has increased, but it remains a challenge to diagnose. CT and MR enterography are noninvasive studies used for evaluation of small bowel neoplasms and inflammatory small bowel pathologic conditions such as celiac disease. The authors review the spectrum of intestinal and extraintestinal findings of celiac disease at CT and MR enterography, as well as its complications, and the importance of recognizing certain imaging features that help in the diagnosis of celiac disease. More common and specific findings of celiac disease such as inversion of the jejunoileal fold pattern and mesenteric lymphadenopathy are reviewed. More uncommon entities that are more frequently associated with refractory or untreated celiac disease, such as ulcerative jejunoileitis, cavitary mesenteric lymph node syndrome, and malignancies including small bowel adenocarcinoma and lymphoma, are described. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. The slide presentation from the RSNA Annual Meeting is available for this article.

Celiac disease diagnosis from endoscopic images based on multi-scale adaptive hybrid architecture model

Objective. Celiac disease (CD) has emerged as a significant global public health concern, exhibiting an estimated worldwide prevalence of approximately 1%. However, existing research pertaining to domestic occurrences of CD is confined mainly to case reports and limited case analyses. Furthermore, there is a substantial population of undiagnosed patients in the Xinjiang region. This study endeavors to create a novel, high-performance, lightweight deep learning model utilizing endoscopic images from CD patients in Xinjiang as a dataset, with the intention of enhancing the accuracy of CD diagnosis.Approach. In this study, we propose a novel CNN-Transformer hybrid architecture for deep learning, tailored to the diagnosis of CD using endoscopic images. Within this architecture, a multi-scale spatial adaptive selective kernel convolution feature attention module demonstrates remarkable efficacy in diagnosing CD. Within this module, we dynamically capture salient features within the local channel feature map that correspond to distinct manifestations of endoscopic image lesions in the CD-affected areas such as the duodenal bulb, duodenal descending segment, and terminal ileum. This process serves to extract and fortify the spatial information specific to different lesions. This strategic approach facilitates not only the extraction of diverse lesion characteristics but also the attentive consideration of their spatial distribution. Additionally, we integrate the global representation of the feature map obtained from the Transformer with the locally extracted information via convolutional layers. This integration achieves a harmonious synergy that optimizes the diagnostic prowess of the model.Main results. Overall, the accuracy, specificity, F1-Score, and precision in the experimental results were 98.38%, 99.04%, 98.66% and 99.38%, respectively.Significance. This study introduces a deep learning network equipped with both global feature response and local feature extraction capabilities. This innovative architecture holds significant promise for the accurate diagnosis of CD by leveraging endoscopic images captured from diverse anatomical sites.

Myocardial function using two dimension speckle-tracking echocardiography in children with celiac disease

The prevalence of cardiac complications linked to celiac disease (CD) is on expanding. This study aimed to evaluate the cardiac function in children with CD using two dimensional speckle tracking echocardiography (2D-STE) to detect early myocardial dysfunction, if any. This cross-sectional study included 40 children with CD as the patient group and 40 healthy age- and sex-matched children served as the control group. High sensitive troponin T (Hs-troponin T), anti-tissue transglutaminase immunoglobulin A (tTG-IgA), hemoglobin, ferritin, albumin, and vitamin D levels were measured in all participants. Conventional, tissue Doppler imaging (TDI), and 2D-STE were performed for all included children. Conventional echocardiographic parameters showed no significant difference between the two groups. Left ventricular global longitudinal strain (LV GLS) obtained by 2D-STE was substantially lower in children with CD than the control group; however, myocardial performance index (MPI) obtained by TDI was significantly higher in children with CD. Hs-troponin T levels were comparable in both groups. LV GLS was positively correlated with hemoglobin, ferritin, and albumin level, but it was inversely correlated with the duration of the disease and anti tTG-IgA.    Conclusion: 2D-STE can detect subclinical early cardiac dysfunction in children with CD and this cardiac injury correlated to the duration and severity of the disease and some nutritional deficiency in these children. What is Known: • The prevalence of cardiac complications linked to celiac disease (CD) is on expanding. • Only one study evaluated cardiac function in children with CD using two dimensional speckle tracking echocardiography (2D-STE). What is New: • Our study found that 2D-STE can detect early subclinical cardiac dysfunction in children with CD. Cardiac injury in theses children correlated to the duration and severity of the disease, hemglobin, ferritin, and albumin levels.

Cross-sectional imaging: current status and future potential in adult celiac disease

Celiac disease (CD), triggered by exposure to gluten in genetically susceptible individuals, is an immune-mediated small bowel disease affecting about 1% of the population worldwide. But the prevalence of CD varies with age, sex, and location. A strict gluten-free diet remains the primary treatment for CD, currently. Most of patients with CD respond well to gluten-free diet with good prognosis, while some patients fail to get symptomatic relief or histological remission (e.g., nonresponsive or refractory CD). Because of heterogeneous clinical appearance, the diagnosis of CD is difficult. Moreover, malignant complications and poor outcomes accompanied with refractory CD present great challenges in disease management. Over the past three decades, cross-sectional imaging techniques (computed tomography [CT] and magnetic resonance imaging [MRI]) play an important role in small bowel inflammatory and neoplastic diseases. Compared with endoscopic techniques, cross-sectional imaging permits clearly presentation of both intraluminal and extraluminal abnormalities. It provides vascular and functional information, thus improving the possibility as diagnostic and follow-up tool. The value of cross-sectional imaging for patients with suspected or confirmed CD has been gradually demonstrated. Studies revealed that certain features suggested by cross-sectional imaging could help to establish the early diagnosis of CD. Besides, the potential contributions of cross-sectional imaging may lie in the evaluation of disease activity and severity, which helps guiding management strategies. The purpose of this review is to provide current overviews and future directions of cross-sectional imaging in adult CD, thus facilitating the understanding and application in clinical practice. CLINICAL RELEVANCE STATEMENT: In this review, we systematically summarized the existing knowledge of cross-sectional imaging in adult CD and analyzed their possible roles in clinical practice, including disease diagnosis, complication identification, treatment evaluation, and prognostic prediction. KEY POINTS: • Regarding a condition described as "celiac iceberg", celiac disease remains underdiagnosed and undertreated. • Cross-sectional imaging is helpful in clinical management of celiac disease, including disease diagnosis, complication identification, treatment evaluation, and prognostic prediction. • Cross-sectional imaging should be considered as the valuable examination in patients suspected from celiac disease.

Small Bowel Imaging in Celiac Disease: Is there a role for Small Bowel Ultrasound?

PURPOSE OF REVIEW

The incidence of celiac disease (CD) has increased over the last decades in part due to better disease awareness. Small bowel ultrasound (sb US) enables dynamic assessment of the bowel; although this topic has been addressed, the use of sb US in the diagnosis and in the follow-up of CD patients is limited to a few specialized tertiary referral centers. Herein, we aimed at summarizing the available literature on this topic to better define the potential clinical implications of sb US in CD, also through a comparison with other available diagnostic techniques.

RECENT FINDINGS

According to available data, sb US can be of help in confirming or excluding CD in patients with clinical suspicion; specifically, the finding of increased gall bladder volume, free abdominal fluid and enlargement of mesenteric lymph nodes reliably and accurately predicts the diagnosis of CD, whereas the absence of bowel dilatation and increased peristalsis may exclude the diagnosis. However, the place of intestinal US in the diagnostic algorithm of CD is likely to vary depending on the probability of the disease in a given population. There are only a few studies on the role of sb US in complicated CD, even if recent reports suggest a possible clinical role. There is a lack of data on follow-up of CD patients, particularly with the aim of detecting a poor diet adherence. According to current data sb US parameters have been shown to be of value in confirming and excluding the diagnosis of CD. Prospective studies with large sample size are warranted to determine whether to include sb US in the available guidelines for CD diagnosis and monitoring.

Advancing dentistry: fractal assessment of bone health in pediatric patients with celiac disease using dental images

OBJECTIVES

To assess the effects of a gluten-free diet on bone structure in children with celiac disease using fractal analysis on panoramic radiographs.

METHOD AND MATERIALS

A total of 49 patients with celiac disease aged 6 to 13 years, separated into two groups as previously and newly diagnosed, and a control group of 32 healthy individuals were evaluated. In previously and newly diagnosed patients with celiac disease, body mass index Z-scores were calculated, calcium, alkaline phosphatase, vitamin D3, and parathormone levels were measured, and bone mineral density Z-scores were obtained from dual energy x-ray absorptiometry. In all patients, the fractal dimensions of the right and left temporomandibular condyles were evaluated with the fractal analysis method on panoramic radiographs.

RESULTS

The mean values of serum biomarker levels and the body mass index and bone mineral density Z-scores for both celiac groups were within the normal reference range. No statistically significant difference was determined between right and left condyle fractal dimensions values in the three groups examined. In terms of both right and left condyle fractal dimensions values, there was a statistically significant difference between groups. The highest fractal dimensions values were determined in the previously diagnosed group.

CONCLUSIONS

Differences in fractal dimensions values were observed among patients with celiac disease following the gluten-free diet. Utilizing fractal analysis on panoramic radiographs can prove valuable for dental practitioners in evaluating bone mineral density due to its cost-effectiveness, easy accessibility, and reduced radiation exposure for patients, enabling them to provide comprehensive oral health care and potential early interventions for patients with celiac disease.

Cerebellar Symptoms in Gluten Sensitivity: a Systematic Review of the Effect of a Gluten-Free Diet on Brain Imaging

Cerebellar manifestations have been described in patients with gluten sensitivity (GS)-related disorders. A better understanding of the neurological manifestations of GS requires the use of neuroimaging techniques. We performed a systematic review on neuroimaging findings in GS patients with cerebellar symptoms. We also included a specific search on neuroimaging findings in GS patients with cerebellar manifestations on a gluten-free diet (GFD). PubMed, Embase, and Bireme were systematically searched to identify studies assessing neuroimaging features of adults with cerebellar manifestations and GS with or without enteropathy on a GFD. Ten studies with a total of 222 adult-GS patients were included. Magnetic resonance imaging was used in 100% of the studies. Cerebellar atrophy was evaluated in 7 studies and observed in 63% of the patients. White matter abnormalities were described in 2 studies. Single-photon emission computed tomography was used in 2 studies, and decreased cerebellar perfusion was detected in 92% of the included patients. No study employed nuclear medicine after the start of GFD. Magnetic resonance spectroscopy (MRS) was performed in 2 studies before and after GFD. An increase in the Naa/Cr ratio in cerebellar vermis was seen in 98% of the cases on a strict GFD. Cerebellar atrophy was found to be a prevalent condition in GS patients. MRS demonstrated to be useful in the follow-up of GS patients with cerebellar manifestations on a GFD. Prospective studies using nuclear medicine imaging are needed to study brain changes in GS patients on a GFD.

Evaluation of the Relationship Between Carotid Intima Media Thickness and Dietary Compliance in Pediatric Celiac Patients: A Single-Center Pilot Study

OBJECTIVES

This study aimed to show the relationship between gluten-free diet (GFD) compliance in Celiac Disease (CD) and early atherosclerotic findings in pediatric patients and to test the effectiveness of carotid-intima-media-thickness (cIMT) to possibly predict long-term compliance to the GFD.

METHODS

Patients from 6 to 18 years of age with a diagnosis of CD confirmed by endoscopic duodenal biopsy who were followed at our hospital's pediatric gastroenterology outpatient clinic between November 2020 and May 2021 were evaluated in this single-center, prospective study. The study patients were divided into two groups according to GFD compliance. Serologic and biochemical tests were conducted routinely during the follow-up period. cIMT was measured using ultrasound for both groups.

RESULTS

A total of 80 patients (GFD-non-compliant: n = 35, GFD-compliant: n = 45) were evaluated. No significant differences were observed between the groups in terms of demographic data and pathology results. The mean cIMT value was 0.44 ± 0.028 mm for the GFD-compliant group and 0.54 ± 0.036 mm for the GFD-non-compliant group, with a statistically significant between-group difference (P < .001). The receiver operating characteristic curve analysis showed an area under the curve of 0.992 (95% confidence interval [CI]: 0.978-1, P < .001) for discrimination of the groups. In addition, a cutoff value of 0.486 mm for cIMT showed 96% (95% CI: 0.83-0.99) sensitivity and 94% (95% CI: 0.79-0.99) specificity for distinguishing GFD-compliant patients from non-GFD-compliant patients.

CONCLUSION

In this study, the relationship between long-term GFD compliance and cIMT was demonstrated in CD. Currently used by some authors for the assessment of preclinical atherosclerosis, cIMT can also be used as a long-term indicator of dietary compliance as well as cardiovascular risk.

Validation of the X-ray microtomography in the assessment of duodenal morphometry and surface area in celiac disease

Background

Duodenal histology remains the diagnostic reference standard in celiac disease. However, traditional methods have suboptimal sensitivity and reproducibility for early mucosal changes and research purposes. We validated a recently introduced micro-CT imaging method for an accurate digital evaluation of duodenal histomorphometry and mucosal surface areas.

Methods

Endoscopic biopsies from 58 individuals were utilized for the micro-CT imaging, selecting histological changes ranging from normal to severely damaged mucosa. The imaging protocol was optimized for practicability and resolution. The Bland–Altman method was applied to test intra- and interobserver variations in the blinded measurements.

Results

The 3D micro-CT reconstructions enabled easy and precise digital cutting with optimal orientation and computer-assisted measurement of the surface area. Intraobserver analysis of morphological measurements showed a mean difference of 0.011 with limits of agreement (LA) from -0.397 to 0.375 and a standard deviation (SD) of 0.197. The corresponding figures for interobserver analysis were 0.080, from -0.719 to 0.537 and 0.320, respectively. The intraclass correlation coefficients (ICC) for the intraobserver and interobserver variations were 0.981 and 0.954, respectively. Intraobserver surface area analysis yielded a mean difference of 0.010, LA from -0.764 to 0.785 and an SD of 0.395, and an interobserver analysis mean difference of 0.028, LA from -0.642 to 0.698 and SD of 0.342. The respective ICCs for the intra- and interobserver variations were 0.963 and 0.972.

Conclusions

Micro-CT showed excellent accuracy and reproducibility in the evaluation of mucosal morphometry and surface areas. The improved sensitivity for histological changes is a powerful tool for the diagnosis of celiac disease and for clinical and pharmacological studies.

Evaluation of eye involvement in paediatric celiac disease patients

BACKGROUND

The non-classic presentation of paediatric celiac disease (CeD) becomes increasingly common in daily practice, which requires an awareness of eye findings. The purpose of this study was to evaluate eye involvement and effect of gluten-free diet on ocular involvement in paediatric CeD patients by measuring the thicknesses of choroid and ganglion cell complex (GCC) composed of retinal nerve fibre layer, ganglion cell layer and inner plexiform layer using enhanced depth imaging optical coherence tomography.

METHODS

Forty-three CeD patients aged between four and 16 years (mean age: 9.9 ± 4.1, 12 boys and 31 girls) and 48 healthy children (mean age: 11.3 ± 4.1,17 boys and 31 girls) were compared. Following comprehensive eye examinations, thicknesses of choroid at three points and GCC layers (retinal nerve fibre layer at five points, ganglion cell layer and inner plexiform layer) were obtained using enhanced depth imaging optical coherence tomography. Measurement of thicknesses of choroid and GCC layers by a trained optical coherence tomography technician and an ophthalmologist who were not aware about group of children in paediatric CeD patients with 1 year gluten-free diet was carried out.

RESULTS

All layers of subfoveal, nasal and temporal choroid were significantly thinner in CeD than in the control group (P < .001, all, respectively). No significant difference was observed between the CeD and control groups in terms of GCC thicknesses (P > .05, all, respectively).

CONCLUSION

Paediatric CeD caused thinning of subfoveal, nasal and temporal areas of choroid, and this change is apparent even after 1 year gluten-free diet. This eye involvement should be more closely screened at diagnosis, and long-term clinical results of thin choroid should be determined. Thicknesses of GCC layers were not different in CeD group and may reveal the effect of diet or not involvement.

Resolution-based distillation for efficient histology image classification

Developing deep learning models to analyze histology images has been computationally challenging, as the massive size of the images causes excessive strain on all parts of the computing pipeline. This paper proposes a novel deep learning-based methodology for improving the computational efficiency of histology image classification. The proposed approach is robust when used with images that have reduced input resolution, and it can be trained effectively with limited labeled data. Moreover, our approach operates at either the tissue- or slide-level, removing the need for laborious patch-level labeling. Our method uses knowledge distillation to transfer knowledge from a teacher model pre-trained at high resolution to a student model trained on the same images at a considerably lower resolution. Also, to address the lack of large-scale labeled histology image datasets, we perform the knowledge distillation in a self-supervised fashion. We evaluate our approach on three distinct histology image datasets associated with celiac disease, lung adenocarcinoma, and renal cell carcinoma. Our results on these datasets demonstrate that a combination of knowledge distillation and self-supervision allows the student model to approach and, in some cases, surpass the teacher model's classification accuracy while being much more computationally efficient. Additionally, we observe an increase in student classification performance as the size of the unlabeled dataset increases, indicating that there is potential for this method to scale further with additional unlabeled data. Our model outperforms the high-resolution teacher model for celiac disease in accuracy, F1-score, precision, and recall while requiring 4 times fewer computations. For lung adenocarcinoma, our results at 1.25× magnification are within 1.5% of the results for the teacher model at 10× magnification, with a reduction in computational cost by a factor of 64. Our model on renal cell carcinoma at 1.25× magnification performs within 1% of the teacher model at 5× magnification while requiring 16 times fewer computations. Furthermore, our celiac disease outcomes benefit from additional performance scaling with the use of more unlabeled data. In the case of 0.625× magnification, using unlabeled data improves accuracy by 4% over the tissue-level baseline. Therefore, our approach can improve the feasibility of deep learning solutions for digital pathology on standard computational hardware and infrastructures.

Celiac Disease Detection From Videocapsule Endoscopy Images Using Strip Principal Component Analysis

The purpose of this study was to implement principal component analysis (PCA) on videocapsule endoscopy (VE) images to develop a new computerized tool for celiac disease recognition. Three PCA algorithms were implemented for feature extraction and sparse representation. A novel strip PCA (SPCA) with nongreedy L1-norm maximization is proposed for VE image analysis. The extracted principal components were interpreted by a non-parametric k-nearest neighbor (k-NN) method for automated celiac disease classification. A benchmark dataset of 460 images (240 from celiac disease patients with small intestinal villous atrophy versus 220 control patients lacking villous atrophy) was constructed from the clinical VE series. It was found that the newly developed SPCA with nongreedy L1-norm maximization was most efficient for computerized celiac disease recognition, having a robust performance with an average recognition accuracy of 93.9 percent. Furthermore, SPCA also has a reduced computation time as compared with other methods. Therefore, it is likely that SPCA will be a helpful adjunct for the diagnosis of celiac disease.

Celiac disease diagnosis from videocapsule endoscopy images with residual learning and deep feature extraction

BACKGROUND AND OBJECTIVE

Videocapsule endoscopy (VCE) is a relatively new technique for evaluating the presence of villous atrophy in celiac disease patients. The diagnostic analysis of video frames is currently time-consuming and tedious. Recently, computer-aided diagnosis (CAD) systems have become an attractive research area for diagnosing celiac disease. However, the images captured from VCE are susceptible to alterations in light illumination, rotation direction, and intestinal secretions. Moreover, textural features of the mucosal villi obtained by VCE are difficult to characterize and extract. This work aims to find a novel deep learning feature learning module to assist in the diagnosis of celiac disease.

METHODS

In this manuscript, we propose a novel deep learning recalibration module which shows significant gain in diagnosing celiac disease. In this recalibration module, the block-wise recalibration component is newly employed to capture the most salient feature in the local channel feature map. This learning module was embedded into ResNet50, Inception-v3 to diagnose celiac disease using a 10-time 10-fold cross-validation based upon analysis of VCE images. In addition, we employed model weights to extract feature points from training and test samples before the last fully connected layer, and then input to a support vector machine (SVM), k-nearest neighbor (KNN), and linear discriminant analysis (LDA) for differentiating celiac disease images from heathy controls.

RESULTS

Overall, the accuracy, sensitivity and specificity of the 10-time 10-fold cross-validation were 95.94%, 97.20% and 95.63%, respectively.

CONCLUSIONS

A novel deep learning recalibration module, with global response and local salient factors is proposed, and it has a high potential for utilizing deep learning networks to diagnose celiac disease using VCE images.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Semiautomatic detection of villi in confocal endoscopy for the evaluation of celiac disease

Celiac Disease (CD) is an immune-mediated enteropathy, diagnosed in the clinical practice by intestinal biopsy and the concomitant presence of a positive celiac serology. Confocal Laser Endomicroscopy (CLE) allows skilled and trained experts to potentially perform in vivo virtual histology of small-bowel mucosa. In particular, it allows the qualitative evaluation of mucosa alteration such as a decrease in goblet cells density, presence of villous atrophy or crypt hypertrophy. We present a semi-automatic method for villi detection from confocal endoscopy images, whose appearance change in case of villous atrophy. Starting from a set of manual seeds, a first rough segmentation of the villi is obtained by means of mathematical morphology operations. A merge and split procedure is then performed, to ensure that each seed originates a different region in the final segmentation. A border refinement process is finally performed, evolving the shape of each region according to local gradient intensities. Mean and median Dice coefficients for 290 villi originating from 66 images when compared to manually obtained ground truth are 80.71% and 87.96% respectively.

Predictors of improvement in bone mineral density after celiac disease diagnosis

PURPOSE

Low bone density is frequently found in patients newly diagnosed with celiac disease (CD), and improvement is variable. This study was performed to assess changes in bone mineral density (BMD) by dual x-ray absorptiometry (DXA) at the lumbar spine, hip, and distal one-third radius as well as clinical predictors of BMD changes after the diagnosis and treatment of CD.

METHODS

Adult CD patients who had serial DXA at the Celiac Disease Center at Columbia University Medical Center were included (N = 103). We assessed within-person changes in BMD with paired t-tests. Multiple regression was utilized to assess baseline clinical and laboratory predictors of BMD improvement after diagnosis and treatment.

RESULTS

The mean age of our sample was 45.6 years (±SD 15.1) and 60% were female. After a median follow-up of 21 months, lumbar spine BMD increased by 1.7 ± 5.5% (p = 0.006) after CD diagnosis. There was a similar trend at the total hip (1.6 ± 6.3%, p = 0.06), but no change at the femoral neck or distal one-third radius. Lower baseline serum calcium predicted a greater increase in lumber spine BMD (ß = -0.0470 g/cm², p = 0.002). At the hip, higher baseline creatinine clearance (ß = 0.005, p = 0.02) was associated with greater gains in BMD.

CONCLUSION

BMD increases at the lumbar spine after the diagnosis of CD and greater BMD improvement is associated with lower baseline serum calcium. This suggests that those with the lowest calcium, which is likely a surrogate for the greatest malabsorption, may have the greatest potential for improvement in skeletal health after treatment of CD.

Prediction of esophageal and gastric histology by macroscopic diagnosis during upper endoscopy in pediatric celiac disease

AIM

To determine the sensitivity of macroscopic appearance for predicting histological diagnosis at sites other than duodenum in pediatric celiac disease (CD).

METHODS

Endoscopic and histologic findings in pediatric patients undergoing upper endoscopy for first-time diagnosis of CD at Stollery Children’s Hospital from 2010-2012 were retrospectively reviewed.

RESULTS

Clinical charts from 140 patients were reviewed. Esophageal and gastric biopsies were taken in 54.3% and 77.9% of patients, respectively. Endoscopic appearance was normal in the esophagus and stomach in 75% and 86.2%. Endoscopic esophageal diagnoses were eosinophilic esophagitis (EE) (11.8%), esophagitis (7.9%), glycogenic acanthosis (1.3%) and non-specific abnormalities (3.9%). Endoscopic gastric diagnoses were gastritis (8.3%), pancreatic rest (0.9%), and non-specific abnormalities (4.6%). Histology was normal in 76.3% of esophageal and 87.2% of gastric specimens. Abnormal esophageal histology was EE (10.5%), esophagitis (10.5%), glycogenic acanthosis (1.3%) and non-specific (1.3%). Gastritis was reported in 12.8% of specimens. Sensitivity and specificity of normal endoscopy for predicting normal esophageal histology was 86.2% and 61.1%, and for normal gastric histology was 87.4% and 21.4%.

CONCLUSION

In the absence of macroscopic abnormalities, routine esophageal and gastric biopsy during endoscopy for pediatric CD does not identify major pathologies. These findings have cost and time saving implications for clinical practice.

Role of capsule endoscopy in suspected celiac disease: A European multi-centre study

AIM

To analyze the diagnostic yield (DY), therapeutic impact (TI) and safety of capsule endoscopy (CE).

METHODS

This is a multi-centre, observational, analytical, retrospective study. A total of 163 patients with suspicion of celiac disease (CD) (mean age = 46.4 ± 17.3 years, 68.1% women) who underwent CE from 2003 to 2015 were included. Patients were divided into four groups: seronegative CD with atrophy (Group-I, n = 19), seropositive CD without atrophy (Group-II, n = 39), contraindication to gastroscopy (Group-III, n = 6), seronegative CD without atrophy, but with a compatible context (Group-IV, n = 99). DY, TI and the safety of CE were analysed.

RESULTS

The overall DY was 54% and the final diagnosis was villous atrophy (n = 65, 39.9%), complicated CD (n = 12, 7.4%) and other enteropathies (n = 11, 6.8%; 8 Crohn’s). DY for groups I to IV was 73.7%, 69.2%, 50% and 44.4%, respectively. Atrophy was located in duodenum in 24 cases (36.9%), diffuse in 19 (29.2%), jejunal in 11 (16.9%), and patchy in 10 cases (15.4%). Factors associated with a greater DY were positive serology (68.3% vs 49.2%, P = 0.034) and older age (P = 0.008). On the other hand, neither sex nor clinical presentation, family background, positive histology or HLA status were associated with DY. CE results changed the therapeutic approach in 71.8% of the cases. Atrophy was associated with a greater TI (92.3% vs 45.3%, P < 0.001) and 81.9% of the patients responded to diet. There was one case of capsule retention (0.6%). Agreement between CE findings and subsequent histology was 100% for diagnosing normal/other conditions, 70% for suspected CD and 50% for complicated CD.

CONCLUSION

CE has a high DY in cases of suspicion of CD and it leads to changes in the clinical course of the disease. CE is safe procedure with a high degree of concordance with histology and it helps in the differential diagnosis of CD.

Sprue-like enteropathy associated with olmesartan in a patient with villous atrophy, HLA-DQ2 genotype and antinuclear antibodies

We describe a new case of enteropathy with villous atrophy in a patient suffering from arterial hypertension treated with olmesartan. The molecular and serological studies showed anti-nuclear antibodies (ANA) and haplotype HLA-DQ2 positive, as well as negative results for anti-transglutaminase, anti-endomysium and anti-enterocytes antibodies. A duodenal villous atrophy was suspected by upper gastrointestinal endoscopy, which was confirmed by histopathology. The morphological picture was suggestive of sprue-like enteropathy with severe lymphoid infiltration and predominant T lymphoid cells.

Extraction and processing of videocapsule data to detect and measure the presence of villous atrophy in celiac disease patients

BACKGROUND

Videocapsule endoscopy is a relative new method to analyze the gastrointestinal tract for the presence of pathologic features. It is of relevance to detect villous atrophy in the small bowel, which is a defining symptom of celiac disease.

METHOD

In this tutorial, methods to extract and process videocapsule endoscopy data are elucidated. The algorithms, computer code, and paradigms to analyze image series are described in detail. The topics covered include extraction of data, analysis of texture, eigenanalysis, spectral analysis, three-dimensional projection, and estimation of motility. The basic paradigms to implement these processes are provided.

RESULTS

Examples of successful quantitative analysis implementations for selected untreated celiac disease patients with villous atrophy versus control patients with normal villi were illustrated. Based on the implementations, it was evident that celiac patients tended to have a rougher small intestinal texture as compared with control patients. From three-dimensional projection, celiac patients exhibited larger surface protrusions emanating from the small intestinal mucosa, which may represent clumps of atrophied villi. The periodicity of small intestinal contractions tends to be slower when villous atrophy is present, and the estimated degree of motility is reduced as compared with control image series. Basis image construction suggested that fissuring and mottling of the mucosal surface is predominant in untreated celiac patients, and mostly absent in controls.

CONCLUSIONS

Implementation of computerized methods, as described in this tutorial, will likely be useful for the automated detection and measurement of villous atrophy, and to map its extent along the small intestine of celiac patients.

Celiac disease in toddler with atypical onset. Case report

Celiac disease is a chronic immune-mediated disorder induced in genetically susceptible individuals after ingestion of gluten proteins. An early diagnosis is of highest importance. Ultrasound might show small-bowel intussusception. We present a toddler with one month history of diarrhea and abdominal ultrasound showing ileo-ileal intussusception. Specific serological markers for celiac disease were positive. The duodenal endoscopy showed normal architecture but pathology indicated fully developed celiac disease (Marsh 3c). In conclusion, toddlers, who have even a short history of diarrhea with ultrasound showing ileo-ileal intussusception, can be suspected of celiac disease by positive serologic markers and can be confirmed by duodenal biopsy and pathology.

Atrial Electromechanical Properties in Coeliac Disease

BACKGROUND

Coeliac disease (CD) is an autoimmune and inflammatory disorder of the small intestine. There is reasonable evidence linking inflammation to the initiation and continuation of atrial fibrillation (AF) in inflammatory conditions. Atrial electro-mechanic delay (EMD) was suggested as an early marker of AF in previous studies. The objectives of this study were to evaluate atrial electromechanical properties measured by tissue Doppler imaging and simultaneous electrocardiography (ECG) tracing in patients with CD.

METHODS

Thirty-nine patients with coeliac disease (CD), and 26 healthy volunteers, matched for age and sex, were enrolled in the study. Atrial electromechanical properties were measured by using transthoracic echocardiography and surface ECG. Interatrial electro-mechanic delay (EMD), left intraatrial EMD, right intratrial EMD were calculated.

RESULTS

There was no difference between CD patients and healthy volunteers in terms of basal characteristics. Patients with CD had significantly prolonged left and right intraatrial EMDs, and interatrial EMD compared to healthy controls (p= 0.03, p= 0.02, p<0.0001, respectively). Interatrial EMD was positively correlated with age, disease duration, anti-gliadin IgG, anti-endomysium and disease status. In multiple linear regression, interatrial EMD was independently associated with disease duration, anti-endomysium and disease status after adjusting for age and sex.

CONCLUSIONS

In the present study, atrial EMDs were found significantly higher in patients with CD compared with healthy individuals. Measurement of atrial EMD parameters might be used to predict the risk of development of AF in patients with CD.

Abnormal Skeletal Strength and Microarchitecture in Women With Celiac Disease

CONTEXT

Osteoporosis is often a presenting sign of celiac disease (CD). Whether skeletal fragility in CD is associated with microarchitectural abnormalities is not known.

OBJECTIVE

The objective of the study was to evaluate microarchitecture and biomechanical properties of bone in CD.

DESIGN

This was a case-control study.

SETTING

The study was conducted at a university hospital outpatient facility.

PATIENTS

Patients included premenopausal women with newly diagnosed CD (n = 33) and healthy controls (n = 33).

MAIN OUTCOME MEASURES

Areal bone mineral density by dual-energy x-ray absorptiometry was measured as was trabecular and cortical volumetric bone mineral density (vBMD) and microarchitecture by high-resolution peripheral computed tomography of the distal radius and tibia. Whole-bone stiffness estimated by finite element analysis. PTH, 25-hydroxyvitamin D, and bone turnover markers were also measured.

RESULTS

Groups had similar age, race, and body mass index. Both groups had sufficient 25-hydroxyvitamin D and normal calcium and PTH. Areal bone mineral density was lower in CD. By high-resolution peripheral computed tomography, CD had lower trabecular vBMD, fewer, more widely, and irregularly spaced trabeculae at both the radius and tibia (8%-33%). At the tibia, they also had lower total density (8%) and thinner cortices (10%). Whole-bone stiffness and failure load were lower (11%-21%) in CD at both sites. Biomechanical deficits were associated with trabecular abnormalities.

CONCLUSIONS

Women with CD had abnormal vBMD and microarchitecture at both the radius and tibia. Trabecular bone was preferentially affected. These deficits were associated with lower estimates of skeletal strength. These findings suggest a potential structural mechanism for skeletal fragility in CD and support further research into the pathogenesis of fracture in this population.

Small bowel imaging in celiac disease

BACKGROUND

Modern small bowel imaging techniques allow detailed depiction of small-intestinal abnormalities. The role of these techniques in the investigation of celiac disease is increasing, especially in patients with suspected complicated celiac disease.

KEY MESSAGES

In general, there is no need for radiological small bowel imaging in uncomplicated celiac disease. It is however important that clinicians and radiologists are aware of certain specific radiological findings that may suggest celiac disease, especially since celiac disease is often not considered in adult patients, and small bowel radiology may be performed before specific tests for celiac disease. Radiological abnormalities can be observed with both conventional small bowel radiology studies, like small bowel follow-through or double-contrast small bowel enteroclysis, and newer modalities, like computed tomography or magnetic resonance enterography or enteroclysis. These signs include a decreased number of jejunal folds, an increased number of ileal folds, small bowel dilatation, wall thickening and intussusception. Extraintestinal abnormalities include mesenteric lymphadenopathy, vascular changes and splenic atrophy. Abnormalities congruent with refractory celiac disease type II include a severe decrease in jejunal folds, infiltration of the mesenteric fat and thickening of the small bowel wall. Additionally, a severely decreased splenic volume may indicate complicated celiac disease. Malignant complications of celiac disease, such as enteropathy-associated T-cell lymphoma and small-intestinal adenocarcinoma, can be reliably investigated with cross-sectional enteroclysis techniques.

CONCLUSIONS

Small bowel imaging and especially cross-sectional enteroclysis techniques are important extensions to the diagnostic workup of clinicians involved in the care of patients with celiac disease, especially those with suspected complicated disease.

Motility alterations in celiac disease and non-celiac gluten sensitivity

Regulation of gut motility is complex and involves neuromuscular, immune and environmental mechanisms. It is well established that patients with celiac disease (CD) often display gut dysmotility. Studies have shown the presence of disturbed esophageal motility, altered gastric emptying, and dysmotility of the small intestine, gallbladder and colon in untreated CD. Most of these motor abnormalities resolve after a strict gluten-free diet, suggesting that mechanisms related to the inflammatory condition and disease process are responsible for the motor dysfunction. Motility abnormalities are also a hallmark of functional bowel disorders such as irritable bowel syndrome (IBS), where it has been proposed as underlying mechanism for symptom generation (diarrhea, constipation, bloating). Non-celiac gluten sensitivity (NCGS) is a poorly defined entity, mostly self-diagnosed, that presents clinically with IBS symptoms in the absence of specific celiac markers. Patients with NCGS are believed to react symptomatically to wheat components, and some studies have proposed the presence of low-grade inflammation in these patients. There is little information regarding the functional characterization of these patients before and after a gluten-free diet. A study suggested the presence of altered gastrointestinal transit in NCGS patients who also have a high prevalence of nonspecific anti-gliadin antibodies. Results of an ongoing clinical study in NCGS patients with positive anti-gliadin antibodies before and after a gluten-free diet will be discussed. Elucidating the mechanisms for symptom generation in NCGS patients is important to find new therapeutic alternatives to the burden of imposing a strict gluten-free diet in patients who do not have CD.

Gluten content of barium sulfate suspensions used for barium swallows in patients with celiac disease

PURPOSE

To determine the availability and accuracy of information provided by hospitals, imaging centers, and manufacturers regarding gluten in barium sulfate suspensions.

METHODS

A total of 105 facilities were contacted via telephone to determine the gluten content of the contrast media used in those facilities. Manufacturers were contacted and their Web sites reviewed to determine the gluten content of their barium products.

RESULTS

Thirty-nine percent of the hospitals and 52% of the imaging centers were not aware of the gluten content of the contrast media they used. Twenty-nine-and-a-half percent of the respondents provided the correct gluten content. The manufacturers noted that 5 products were tested and confirmed gluten free, 1 product was not tested but described as gluten free, 1 product's gluten content depended upon its flavor, and 1 product was reported to contain gluten.

DISCUSSION

Clinicians caring for patients with celiac disease or patients who choose to restrict their gluten consumption must ensure that the barium sulfate suspension ingested is gluten free.

CONCLUSION

It can be difficult to determine the gluten content of barium sulfate, as a majority of radiology departments and imaging centers did not know whether the product they use is gluten free. Educating staff members and improving product labeling would benefit the quality of care provided to patients with celiac disease.

Subclinical synovitis detected by ultrasound in children affected by coeliac disease: a frequent manifestation improved by a gluten-free diet

OBJECTIVES

Coeliac disease (CD) is a chronic autoimmune disease of the small intestine caused by the ingestion of gluten, in which musculoskeletal manifestations may occur. Aim of this study was to evaluate the prevalence and severity of joint involvement in paediatric patients with CD using musculoskeletal ultrasound (US).

METHODS

Consecutive paediatric CD patients were enrolled and underwent US evaluations at level of knees, hips and ankles. The presence of joint effusion (JE), synovial hypertrophy, power Doppler signal and structural damage lesions (bone irregularities and erosions) was registered. Inflammatory abnormalities were scored on a semi-quantitative scale (0-3), and structural damage lesions on a dichotomous scale (0-1).

RESULTS

Seventy-four CD children (mean age: 7.6 years; range: 1-14.2; M/F 24/50) were enrolled. Thirty-eight were on a gluten-containing diet (GCD) and 36 on a gluten-free diet (GFD). US showed the presence of abnormalities in 23 patients overall (31.1%); JE was the most frequently observed change (23/23). US abnormalities were observed in 19 patients (50.0%) of GCD group and in 4 of GFD group (11.1%, p=0.007). Interestingly, 12/23 (52.2%) patients with US-detected changes were asymptomatic.

CONCLUSIONS

This is the first US study demonstrating joint involvement in children with CD. JE, the most frequent manifestation, was present also in asymptomatic patients and was reduced in those on GFD. These findings may indicate that, also at joint level, an inflammatory response represented by the appearance of JE may be induced by exposure to gluten.

Computed tomography of celiac disease

Celiac disease is an autoimmune disorder that causes inflammation and destruction in the small intestine in response to the ingestion of gluten and related proteins. Although long considered a pediatric condition, it is now recognized as a condition that affects all ages, with significant complications if it goes untreated. Adults are most likely to present for imaging without a diagnosis for unspecified abdominal symptoms. Imaging the small intestine is complicated. Although the advent of multidetector computed tomography (CT) helps, the relative newness of its use, combined with the relative scarcity of imaging studies of celiac disease, make CT imaging of celiac disease a constantly evolving arena.

[Intraoperative ultrasound duplex scanning in the diagnosis and assessment of results of surgical treatment of patients with celiac compression syndrome]

The authors have performed an analysis of main indicators of celiac duplex scanning in 180 patients with celiac compression syndrome before operation, during decompression and at the postoperative period. All the patients underwent surgical celiac trunk decompression. The indicators of the intraoperative celiac duplex scanning (stenosis degree, linear peak systolic circulation rate) of the celiac trunk shower hemodynamic reliable stenosis and were sufficiently different from preoperative findings. The stenosis degree and linear peak systolic circulation rate were less during intraoperative examination than before the operation. Intraoperative, duplex canning allowed compressive stenosis of the seliac trunk to be differentatied in some patients from intravasal one (atherosclerosis and arteritis), and its adequate decompression to be performed. When performing the celiac trunk decompression it is thought to be necessary to fulfill its intraoperative ultrasound duplex scanning before and after elimination of the compression.

A key role for abdominal ultrasound examination in "difficult" diagnoses of celiac disease

PURPOSE

To evaluate the usefulness of abdominal ultrasound examination (US) for the diagnostic workup of cases of suspected CD involving negative serum antibodies and difficult diagnosis.

MATERIALS AND METHODS

524 consecutive patients with symptoms of suspected CD underwent an extensive diagnostic workup. 76 (14 %) were excluded since they were positive for serum anti-tTG and/or EmA antibodies. 377 were excluded since they were diagnosed with something other than CD or did not have the alleles encoding for HLA DQ 2 or DQ 8. A diagnosis of CD with negative serum antibodies was probable in 71 patients who underwent abdominal US and duodenal biopsy for histology evaluation.

RESULTS

Intestinal histology and subsequent clinical and histological follow-up confirmed the CD diagnosis in 12 patients (GROUP 1) and excluded it in 59 subjects (GROUP 2). Abdominal US showed that the presence of dilated bowel loops and a thickened small bowel wall had a sensitivity of 83 % and a negative predictive value (NPV) of 95 % in CD diagnosis. Furthermore, in 11 of the 12 CD seronegative patients there was at least one of these two abdominal US signs. Therefore, considering the presence of one of these two signs, abdominal US sensitivity increased to 92 % and NPV to 98 %.

CONCLUSION

Abdominal US is useful in the diagnostic workup of patients with a high clinical suspicion of CD but with negative serology.

Osteodystrophy in celiac disease: ultimate complications and possible treatment

Hypovitaminosis D and its consequences are significant complications in the course of untreated celiac disease (CD). We report a case that illustrates the natural evolution of osteomalacia in an adult patient with untreated CD and his response to vitamin D supplementation. In patients with complicated CD and hypovitaminosis D, vitamin D-2 replacement in high enough doses is important to improving functional performance and for the treatment of osteomalacia.

The influence of gluten free diet on quantitative ultrasound of proximal phalanxes in children and adolescents with type 1 diabetes mellitus and celiac disease

A reduced bone mineral density has been reported in patients with untreated celiac disease (CD) as well as in patients with poorly controlled type 1 diabetes mellitus (T1DM). The aim of this study was to evaluate the bone mineral status by phalangeal quantitative ultrasound in 52 children and adolescents with both diseases (mean age 13.3+/-4.9 years). As a control group 50 patients with T1DM and no CD (age 12.2+/-4.0 years) were studied. The following bone parameters, amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT) were considered and expressed as z score. Compliance to gluten free diet and long term glycemic control (mean of four determinations of HbA1c in the last year) were also assessed. The lowest mean AD-SoS z score values were found in patients with T1DM and CD, who reported transgressions to gluten free diet and exhibited positivity for serum anti-tissue transglutaminase antibodies (tTG) and/or endomysial antibodies (EmA), compared with patients with occasional transgressions but negative for anti-tTG and/or -EmA, patients strictly adherent to the diet, and patients who suffered only from diabetes (ANOVA p=0.021). No difference was found between patients with diabetes alone and patients with both diseases strictly adherent to gluten free diet. Prevalence of osteopenia (z AD-SoS values <-2 SD) was higher in patients with T1DM and CD and poor compliance to the diet (45.5%) compared with patients with T1DM (8%) or patients with both diseases strictly compliant to diet (12.9%) (p=0.015). A negative correlation between Ad-SoS z score and HbA1c (r -0.236, p=0.036) was found when patients with T1DM and patients with T1DM and CD, who strictly adhere to the diet, were pooled. In conclusion the quality of bone as assessed by phalangeal ultrasound in patients with T1DM and CD, who strictly adhere to gluten free diet, is similar to that found in T1DM patients. A higher prevalence of osteopenia is present in patients with both diseases who reported habitual transgressions to gluten free diet. The gluten free diet, as well as the optimization of glycemic control, plays an important role in preventing the osteopenic status caused by the clustering of these two chronic diseases.

13C-xylose and 14C-xylose breath tests for the diagnosis of coeliac disease

OBJECTIVES

Xylose absorption testing has traditionally involved measurement of serum xylose and/or measurement of excreted xylose in urine. However, by enriching xylose with a 13C- or 14C-isotope, absorption of an oral xylose load will be reflected in the time-dependent pattern of 13CO2 or 14CO2 exhaled in breath. Our objectives were to evaluate the diagnostic properties of 13C-xylose and 14C-xylose breath tests in coeliac disease, and to develop a diagnostic breath test index.

MATERIAL AND METHODS

We reviewed data from 41 coeliac patients who underwent the 14C-xylose breath test before and after commencement of a gluten-free diet, and 60 coeliac patients who underwent the 13C-xylose breath test, 37 of whom repeated the test after starting a gluten-free diet. Coeliac patients were compared with healthy control subjects.

RESULTS

Coeliac patients exhaled significantly less 13CO2 or 14CO2 than healthy controls during the first hour of the test and more isotope-labelled CO2 than control subjects after 3 h. Diagnostic accuracy was optimal with test duration of 210 min combining gas measurements at 30 min and 210 min in a simple fraction. This gas fraction index (30 min/210 min) distinguished between coeliac patients and healthy control subjects with 84-95% sensitivity and 87-94% specificity. After commencement of a gluten-free diet, the gas fraction index increased in most coeliac patients, but remained lower than that in healthy control subjects.

CONCLUSIONS

13C-xylose- and 14C-xylose breath tests discriminate between coeliac patients and healthy control subjects with high sensitivity and specificity. The stable isotope 13C-xylose breath test has comparable diagnostic accuracy to the radioactive isotope 14C-xylose breath test and should be the preferred alternative to traditional xylose absorption tests.

The imaging of coeliac disease and its complications

Coeliac disease is a malabsorption syndrome in which dietary gluten damages the small bowel mucosa. Gluten contains gliadin, the primary toxic component that is primarily found in wheat, barley and rye products. The initial diagnosis of coeliac disease is usually made by endoscopic biopsy of the jejunum although sometimes imaging features can suggest the diagnosis. Once a diagnosis is made, patients need to be diet compliant and monitored for potential complications. Many complications are more common when dietary compliance is poor. Complications include intussusception (usually intermittent), ulcerative jejunitis, osteomalacia, cavitating lymph node syndrome and an increased risk of malignancies such as lymphoma, adenocarcinoma and squamous cell carcinoma. Radiological evaluation is central in the evaluation of these complications. Imaging may assist both in the diagnosis and staging of complications as well as enabling radiological guided percutaneous biopsy for complications of coeliac disease such as lymphoma. As coeliac disease is a relatively common disorder, it is likely that most radiologists will encounter the disease and its potential complications. The aim of this review article is to discuss and illustrate the role of modern radiology in evaluating the many presentations of this complex disease.

Intramural Fat in the Duodenum and Proximal Small Intestine in Patients with Celiac Disease

OBJECTIVE

The purpose of this article is to describe and illustrate intramural fat in the duodenum and jejunum, to our knowledge a previously undescribed finding in celiac disease.

CONCLUSION

Celiac disease is known to produce inflammation of the duodenum and jejunum. We propose that postinflammatory intramural fat deposition occurs in a distribution likely unique for celiac disease. CT scans of the chest and abdomen obtained for many indications include these portions of the bowel. Celiac disease is now recognized as a common disease, and the recognition of intramural fat in the duodenum and jejunum on CT may allow earlier diagnosis.

Prospective peer-review audit of paediatric upper gastrointestinal endoscopy

AIM

To describe the findings of paediatric upper gastrointestinal endoscopy (UGE) and to reduce the rate of normal findings in children undergoing diagnostic UGE.

METHODS

Upper gastrointestinal endoscopy were performed at a single tertiary referral children's hospital over a 3-year period by four endoscopists. Patients were subgrouped into diagnostic categories (recurrent abdominal pain syndrome (RAP), oesophagitis, coeliac disease and enteropathy/inflammatory bowel disease) and endoscopists recorded their clinical diagnosis as above before each procedure. Endoscopic and biopsy findings were compared with clinical diagnosis. After the first year of audit each endoscopist was appraised of their practice and strategies implemented to reduce the normal UGE. In years 2 and 3 all endoscopists were audited by their peers on a monthly basis.

RESULTS

A total of 1172 UGE were performed over a 3-year period. Ninety per cent were diagnostic procedures, of which 48% were normal, 16% identified oesophagitis, 11% coeliac disease, 6% gastritis, 3%Helicobacter pylori and 1% peptic ulcer disease. Peer-review audit significantly reduced the number of normal findings in coeliac disease, RAP and overall (P < 0.01) but not in the groups with presumed oesophagitis or investigation of enteropathy/inflammatory bowel disease.

CONCLUSIONS

A high proportion of patients undergoing UGE have normal procedures. Peer-review audit can reduce the number of normal procedures particularly in RAP and in the diagnosis of coeliac disease.

Abdominal computed tomography in refractory coeliac disease and enteropathy associated T-cell lymphoma

AIM: To evaluate computed tomography (CT) findings, useful to suggest the presence of refractory celiac disease (RCD) and enteropathy associated T cell lymphoma (EATL).

METHODS: Coeliac disease (CD) patients were divided into two groups. GroupI: uncomplicated CD (n = 14) and RCD typeI(n = 10). Group II: RCD type II (n = 15) and EATL (n = 7).

RESULTS: Both groups showed classic signs of CD on CT. Intussusception was seen in 1 patient in groupIvs 5 in group II (P = 0.06). Lymphadenopathy was seen in 5 patients in group II vs no patients in groupI(P = 0.01). Increased number of small mesenteric vessels was noted in 20 patients in groupIvs 11 in group II (P = 0.02). Eleven patients (50%) in group II had a splenic volume < 122 cm³vs 4 in groupI(14%), 10 patients in groupI had a splenic volume > 196 cm³ (66.7%) vs 5 in group II (33.3%) P = 0.028.

CONCLUSION: CT scan is a useful tool in discriminating between CD and (Pre) EATL. RCD II and EATL showed more bowel wall thickening, lymphadenopathy and intussusception, less increase in number of small mesenteric vessels and a smaller splenic volume compared with CD and RCDI.

Small bowel ultrasound in patients with celiac disease. Retrospective study

OBJECTIVE

Celiac disease (CD) is a common, lifelong disease with small bowel malabsorption based on genetically conditioned gluten intolerance. The clinical manifestation could be very heterogeneous. The proof of celiac disease is now based mainly on clinical and laboratory (antibodies and enterobiopsy) signs, which are in some cases problematic and inconvenient.

MATERIALS AND METHODS

In our study we have examined 250 patients with suspection or with proven celiac disease and we evaluated specific ultrasound small bowel changes in this group. In the next step, we chose 59 patients with laboratory proved celiac disease and we statistically compared ultrasound, other laboratory and clinical findings in different forms and stages of the disease.

RESULTS

Specific small bowel pathologies in patients with celiac disease (like changes of intestinal villi in different parts of small bowel, abnormal peristalsis and mesenterial lymphadenopathy) can be well visualized by ultrasound and in combination with clinical and laboratory signs ultrasound examination could have an important role in screening, determination of diagnosis and monitoring of patients with different forms of celiac disease.

Bowel sonography in adult celiac disease: diagnostic accuracy and ultrasonographic features

BACKGROUND

Celiac disease (CD) is a chronic intolerance to gluten, which induces intestinal mucosal lesions in genetically predisposed individuals. Transabdominal bowel sonography (TABS) is a safe and noninvasive procedure that allows to detect intestinal abnormalities in many conditions, but actually is not routinely part of the diagnostic management of CD.

AIM

To evaluate the diagnostic accuracy of TABS in CD patients.

PATIENTS AND METHODS

Fifty CD patients and 50 dyspeptic subjects (control group) underwent TABS. The presence of fluid-distended small bowel loops with thickened valvulae conniventes and increased peristalsis was considered a TABS sign of CD. All clinical, biochemical, and TABS features were assessed at the diagnosis and revaluated after 1 year of gluten-free diet.

RESULTS

TABS signs were present in 66% of CD patients. Sensitivity, specificity, positive and negative predictive value were 66%, 96%, 94%, and 74%, respectively. TABS findings were recorded in 82% of patients with endoscopical markers of CD, in 87.5% of symptomatic patients, and in 61% of patients without symptoms. After 1 year of gluten-free diet TABS was still abnormal in 20% patients, with no correlation with laboratory tests e/o symptoms.

CONCLUSIONS

Patients with CD frequently present TABS signs of the disease and operators performing sonography every day have to consider the possibility to suggest CD diagnosis and aTTG determination in these subjects.

The role of ultrasonography in patients with celiac disease

The aim of the present review was to summarize the current evidence on the role of ultrasonography (US) and doppler-US in the diagnosis of celiac disease.

Several ultrasonographic signs have been reported in the association with celiac disease in studies using real-time US. Firstly, case control studies identified some of these US signs and then in a prospective series some of these parameters, due to their high specificity, have been shown to be of value in confirming CD diagnosis, whereas others, due to their high sensitivity, have been demonstrated to be useful in excluding the presence of the disease.

The pattern of splanchnic circulation in CD have extensively been investigated by several studies all of which reported similar results and identified a hy-perdynamic mesenteric circulation that reverts to no-rmal values after successful a gluten-free regimen.

The last part of this review will deal with the possible role of US in identyfing the most severe and common intestinal complication of CD, i.e. the enteropathy-associated T cell non-Hodgkin lymphoma.

Sonographic diagnosis of coeliac disease in a case with suspected acute liver failure

Mild liver dysfunction occurs in patients with coeliac disease frequently, but severe liver diseases in combination with coeliac disease are rare. A 19-year-old woman was referred for evaluation for emergency liver transplantation with progressive jaundice and prolongation of prothrombin time. She had a history of non-bloody diarrhoea for 3 months and weight loss of 12 kg. At admission, abdominal ultrasound revealed liver enlargement with increased echogenicity and marked thickening of the circular folds of the small intestine, suggestive of coeliac disease. The diagnosis was confirmed by endoscopic biopsy from the second part of the duodenum. On a gluten-free diet the patient recovered within 1 week and remained in excellent health up to the present date. Liver tests normalized within 5 months and a repeat abdominal ultrasound after 20 months revealed a normal liver and small intestine. This case report suggests that coeliac disease should also be considered in patients with unexplained severe acute liver disease and that abdominal ultrasound may be a helpful step to obtain to the correct diagnosis.

Small intestinal contrast ultrasonography-based scoring system: a promising approach for the diagnosis and follow-up of celiac disease

BACKGROUND

Small intestinal ultrasonography with anechoic contrast agents (SICUS) has been shown to have a diagnostic accuracy on small bowel morphology similar to X-ray barium follow-through. Although extremely investigated by transabdominal ultrasonography, celiac disease, a common disorder of the small bowel, has been never studied by SICUS.

AIM

To asses SICUS characteristics of celiac disease patients.

PATIENTS AND METHODS

SICUS was performed using PEG 4000 as contrast agent. Twenty-three patients with celiac disease at the first diagnosis were enrolled and 30 healthy volunteers, matched for sex and age, were selected as control group. Celiac disease diagnosis was based on anti-gluten, anti-endomysium, and anti-transglutaminase positivity as well as jejunal histology. The following seven echographic parameters were considered: liquid endoluminal content before contrast, loop diameter, Kerckring's folds, peristaltic waves, ileal jejunalization, mesenteric lymphoadenomegaly, and Doppler resistance index (RI) of mesenteric superior artery. Statistical analysis was performed by Student's t test for unpaired data; one-way analysis of variance was used to correlate echographic and histologic pictures.

RESULTS

Loop diameter, Kerckring's fold number, peristaltic waves, and Doppler RI appeared to be significantly different between celiac disease patients and controls. Additionally, liquid content, ileal jejunalization, and mesenteric lymphoadenomegaly were present only in the celiacs (52.1%, 47.7%, and 95.6%, respectively), but not in controls. Only Doppler RI values significantly correlated with the histologic degree of damage.

CONCLUSIONS

SICUS could be a reliable and noninvasive technique to confirm a diagnosis of celiac disease performed using conventional investigations. The possibility of investigating the whole small bowel and the safety of repeating examinations could be useful in the follow-up of celiac patients.